HESI Fundamentals - Set 2 - Part 3

Correct Answer: Pain is what patient reports

Pain is whatever the patient says it is, and the report itself is the gold standard. Patients cope through humor and conversation; the nurse documents the report and treats per the plan accordingly. Option b is incorrect because Body language can be misleading because patients use distraction and humor as coping strategies. Verbal reports remain the standard for pain assessment; non-verbal cues add information but do not replace the patient's words. Option c is incorrect because Vital signs are unreliable indicators of pain because they normalize over time even with significant pain. Heart rate and blood pressure may not rise during chronic pain, and they do not measure the experience. Option d is incorrect because Requiring visible distress before treating pain undertreats most patients and leads to needless suffering. Pain treatment is based on the report and clinical context, not on whether the patient looks miserable.

Correct Answer: FLACC behavioral observation tool

FLACC assesses face, legs, activity, cry, and consolability in children too young to self-report. The tool produces a behavior-based pain score that nurses can use for treatment decisions and ongoing reassessment. Option a is incorrect because A numeric scale requires self-report and is not validated for preverbal toddlers. The child must understand numeric concepts to use the tool, which is beyond the developmental stage at this age. Option c is incorrect because A visual analog scale also requires the patient to mark a line, beyond the ability of preverbal toddlers. The tool works in older children and adults able to translate sensation into a position. Option d is incorrect because Wong-Baker faces work in children old enough to point at a face, often around three years. Below that age, the child cannot reliably select a face, so a behavioral tool is needed instead.

Correct Answer: Chronic pain often shows normal vital signs

Chronic pain often presents with normal vital signs because the body adapts over time. The nurse cannot rely on tachycardia or hypertension to confirm pain in chronic conditions and should still trust the patient's report. Option a is incorrect because Acute pain by definition has a shorter time course than chronic pain and resolves with healing. Confusing the two leads to mismanagement, since chronic pain often persists for months and requires different treatment plans. Option b is incorrect because Chronic pain rarely shows the autonomic vital sign changes seen in acute pain. The body adapts to long-standing pain, so heart rate and blood pressure may stay normal even when pain is severe. Option c is incorrect because Acute pain typically has a clear cause, such as surgery, injury, or inflammation. Chronic pain may have less obvious or harder-to-identify origins, which can complicate management and require multimodal approaches over time.

Correct Answer: Scheduled acetaminophen plus opioid plus ice

Combining scheduled acetaminophen, opioid as needed, and a non-pharmacologic measure like ice covers multiple pain pathways. The approach reduces opioid requirements while still addressing breakthrough pain and inflammation through several mechanisms safely. Option a is incorrect because Opioid monotherapy increases doses, side effects, and the risk of respiratory depression. Multimodal analgesia exists specifically to avoid relying on opioids alone and to broaden the relief through different complementary mechanisms. Option b is incorrect because Heating pad alone is unlikely to control postoperative pain adequately, especially after a major procedure. Multimodal therapy includes pharmacologic agents, and removing them entirely makes pain control difficult and incomplete for this patient. Option d is incorrect because Distraction can supplement other strategies but is not stand-alone analgesia after surgery. The patient still needs pharmacologic agents to address tissue injury and inf

Correct Answer: Reassess within fifteen minutes after intravenous dose

Intravenous opioids reach peak effect within fifteen to thirty minutes, so reassessment around fifteen minutes is appropriate. The nurse evaluates pain reduction, sedation level, respiratory rate, and any side effects after each dose. Option b is incorrect because Sixty minutes is too long for intravenous opioid reassessment, since the peak effect has already passed. Earlier reassessment captures the medication's action and allows timely response to either inadequate relief or adverse effects. Option c is incorrect because Waiting until end of shift skips multiple reassessment windows and ignores the cycle of dosing and response. The nurse must reassess after every dose and again at intervals matching the medication's pharmacokinetics. Option d is incorrect because Four hours after an intravenous dose is well past the peak and does not capture the medication's effect. Oral medications need reassessment around an hour, but intravenous routes work much faster.

Correct Answer: Note appearance, posture, and overall behavior

The general survey notes overall appearance, posture, hygiene, affect, and apparent distress. These cues guide the nurse on how quickly to proceed and which systems may need closer focus during the rest of the assessment. Option a is incorrect because Auscultating bowel sounds is part of the abdominal exam and not the first step. The general survey precedes any system-specific assessment and provides the broad impression needed before zooming in anywhere. Option b is incorrect because Palpating the abdomen comes after auscultation and inspection of that region. Jumping to palpation without the general survey misses important context and could alter findings on subsequent abdominal auscultation. Option c is incorrect because Inspecting a single skin lesion in detail is appropriate during the integumentary exam, not the opening step. The nurse needs the global view first and then drills into specific findings systematically.

Correct Answer: Reassess level of consciousness and vital signs

A sudden change in level of consciousness signals possible neurologic, metabolic, or cardiac compromise. Reassessing level of consciousness, vital signs, and oxygen saturation guides immediate action and the call to the provider. Option a is incorrect because Continuing routine charting ignores a critical change that could indicate stroke, hypoglycemia, or sepsis. The nurse must act on the cue immediately, not wait until the next charting cycle to investigate. Option b is incorrect because Encouraging a nap normalizes a dangerous change and risks deeper deterioration. Drowsiness with confusion is a red flag that requires assessment, not rest, especially in a patient with no recent medication change. Option d is incorrect because Waiting until shift change leaves a possible emergency unmanaged for hours. Acute changes in mentation are time-sensitive findings that must be evaluated and reported promptly to the provider on duty.

Correct Answer: Possible pneumonia requiring further workup

Persistent coarse crackles in bilateral lower lobes plus fever and fatigue raise concern for pneumonia. The nurse documents the findings, monitors oxygen saturation, and notifies the provider for further workup and possible imaging. Option b is incorrect because Coarse persistent crackles are not normal even in older adults and should not be ignored. Treating them as benign delays recognition of an infectious or fluid-related process that may need treatment quickly. Option c is incorrect because Wheezes are high-pitched musical sounds usually heard during expiration, not coarse crackles. The clinical picture also fits an infectious process more than an asthma flare in this scenario today. Option d is incorrect because Pleural friction rub is a grating sound heard with inspiration and expiration that does not change with coughing. The findings here are crackles, not a rub, and the location is bilateral rather than focal.

Correct Answer: Inspect, auscultate, percuss, then palpate

The abdominal sequence is inspect, auscultate, percuss, then palpate. Auscultation comes before any mechanical contact, since pressing or tapping can alter bowel sound character and produce inaccurate findings on the chart. Option a is incorrect because Starting with palpation alters bowel sounds before they are heard and can worsen tenderness. The order also misplaces inspection at the end, when the broad visual impression should guide everything that follows. Option c is incorrect because Palpating before auscultation alters bowel sound patterns and may miss baseline activity. The recommended order keeps mechanical contact for last so listening produces an accurate record of the patient's bowel function. Option d is incorrect because Beginning with auscultation skips inspection and may also miss visual cues like distention or scars. The standard sequence places inspection first so the nurse knows where to focus listening and palpation effectively.

Correct Answer: Color, temperature, pulse, sensation, movement

Neurovascular checks include color, temperature, pulse, capillary refill, sensation, and movement. The elements together detect compromise of arterial flow, venous return, and nerve function in the limb that wears the cast. Option a is incorrect because Vital signs do not provide limb-specific neurovascular information. The nurse needs distal limb data to detect compartment syndrome or nerve injury, and central vital signs cannot show those local problems. Option b is incorrect because Pupillary reflex and eye movement are part of a neurologic exam, not a neurovascular check on a cast. The limb assessment focuses on circulation and sensation distal to the injury rather than central neurology. Option c is incorrect because Bowel sounds and abdominal palpation belong to the abdominal exam and do not assess limb neurovascular status. The nurse uses peripheral findings rather than gastrointestinal data to monitor for cast complications today.